THE DELIBERATE PRACTICE OF PROCEDURAL NURSING SKILLS: EFFECTS OF BLOCK-RANDOM SEQUENCING ON LONG-TERM RETENTION A dissertation submitted to Kent State University in partial fulfillment of the requirements for the degree of Doctor of Philosophy by Andrew Jude Cerniglia November 20, 2019 © Copyright, 2019 by Andrew Jude Cerniglia All Rights Reserved ii Dissertation written by Andrew Jude Cerniglia B.S., Mount Union College, 2000 M.S., Indiana Wesleyan University, 2004 Ph.D., Kent State University, 2019 Approved by , Chair, Doctoral Dissertation Committee Brad Morris , Member, Doctoral Dissertation Committee Chris Was , Member, Doctoral Dissertation Committee Albert Ingram Accepted by , Director, School of Lifespan Development and Mary Dellman-Jenkins Educational Sciences , Dean, College of Education, Health and James C. Hannon Human Services iii CERNIGLIA, ANDREW J., Ph.D., December, 2019 Educational Psychology THE DELIBERATE PRACTICE OF PROCEDURAL NURSING SKILLS: EF- FECTS OF BLOCK-RANDOM SEQUENCING ON LONG-TERM RETENTION (79 pp.) Director of Dissertation: Bradley J. Morris, Ph.D. The primary purpose of the study was to determine whether the block ran- domization of deliberately-practiced nursing skills results in an increase in long- term retention. The study utilized a pre-test post-test, within-subjects design. Stu- dent performance was assessed prior to and immediately after training. Sterile dressing change and venipuncture skills were practiced, with each subject prac- ticing one of the skills procedurally and the other skill in block-random fashion. A practical measure of long-term retention was administered three weeks after training. A total of 46 subjects began the study. However, absences on training days and attrition from second to third quarter of the program depressed participa- tion. Thirty adult education LPN students at a small, midwestern vocational school, ranging in ages from 20 to 58 and averaging 30 years of age completed all components of the study. Thirteen of the 30 subjects had completed varying degrees of post-secondary coursework. Results failed to demonstrate significant differences for practice condition and the interaction of time and practice condition. A main effect for time was realized for both skills. The pre-announced nature of the measure of long-term retention may have obscured additional effects. A more tightly controlled study, utilizing applied pre- and post-assessments, in addition to an unannounced measure of long-term retention could answer these questions more definitively. A lab of pro- grammable, high fidelity simulators would allow for the automation and precise control of such a study. ACKNOWLEDGEMENTS I found this process to be a reminder of how inconsequential we are as individual actors in the word. I will be forever grateful for the patience, understanding, guidance, and support of my advisors Dr. Morris, Dr. Ingram, and Dr. Was. I want to especially thank the nursing faculty who spent many hours accomadating my requests, modifying their curriculum, and altering their work schedules to fit the requirements of the study. Finally, to my wife and parents who offered their support but always couched in the expectation I would successfully complete this journey, thank you. iv DEDICATION This composition is dedicated to my five children. May they value work, find their passion, and love. v TABLE OF CONTENTS ACKNOWLEDGEMENTS . iv DEDICATION . v LIST OF FIGURES . viii LIST OF TABLES . ix I INTRODUCTION . 1 II REVIEW OF THE LITERATURE . 9 Optimizing Performance During Acquisition . 9 Improving Performance After a Delay . 14 Summary . 22 III METHODS . 27 Participants . 27 Materials . 28 Procedures . 29 Coding . 31 vi IV ANALYSIS OF THE FINDINGS . 35 Sterile Dressing Change . 35 Venipuncture . 37 V DISCUSSION, LIMITATIONS, AND RECOMMENDATIONS . 38 Limitations . 40 Recommendations . 43 APPENDICES . 45 APPENDIX A: VENIPUNCTURE CHECKLISTS . 46 APPENDIX B: STERILE DRESSING CHANGE CHECKLISTS . 52 REFERENCES . 56 vii LIST OF FIGURES 1 Example Study Sequences . 32 2 Study Design . 33 3 Subject performance: sterile dressing change . 36 4 Subject performance: venipuncture . 37 viii LIST OF TABLES 1 Within-Subjects Design . 30 ix 1 CHAPTER I INTRODUCTION Medical professionals are tasked with making decisions in real time based on an analysis of their patients. Emergency room physicians are an ideal example of this requirement, but even the nurse aide is required to make minor decisions regarding patient care during each shift. Complicating matters is the number of variables, sometimes confounding, that must be considered, and the fact that some decisions are related to conditions or circumstances encountered only periodically. In order to successfully navigate this com- plex problem space, medical professionals employ analytic and non-analytic systems to integrate background knowledge with information collected in real time through inter- actions with patients (Eva, 2005). The combination of these two systems, an intuitive approach also referred to as \System 2" and \System 1"(Kahneman, 2011), has been shown to be superior to either employed in isolation, even for novices (Eva, 2005). While medical doctors diagnose conditions, prescribe treatment, and perform proce- dures, nurses are the primary practitioners of day-to-day patient care. They serve as intermediaries, interacting with patients frequently, assessing their condition, incorpo- rating information gleaned through dialogue, all while demonstrating empathy and an understanding of the patient's condition. As a result of this complexity, nurse education 2 programs necessarily address the cognitive, psychomotor, and affective domains (Nehring & Lashley, 2008). Instruction takes place in a variety of settings, including the traditional classroom, in the lab setting, and in the field. Educators seek to utilize this combination to integrate a comprehensive understanding of human disease with associated practical skills and an empathetic approach to human care. One dilemma facing nurse educators is deciding how and when to initiation practice on real patients. Fidelity is highest in the clinical setting, however stakes are high. Adequate supervision and prior training are critical. Moreover, while basic everyday nursing skills are practiced later in programs in the clinical setting, the more advanced skills may not be available for practice based on the group of patients admitted to a clinical site when students are completing their rotation. This reality, coupled with the fact that students and professionals lack consistent access to feedback and opportunities for practice aimed at the correction of errors has made simulated laboratory experiences the chosen option for improvement Issenberg, McGaghie, and Hart (1999). Laboratory experiences provide a safe environment for beginning the process of inte- grating knowledge and skills to the degree required for graduation to the clinical setting. As Kaakinen and Ellyn (2009) notes, it is quite possible for a student to perform a skill or a sequence of skills correctly, but mindlessly, i.e., without an understanding of the un- derlying rationale for their actions. The laboratory environment seeks to extinguish this possibility by allowing for repetition and reflection. The instructor monitors performance 3 and assesses understanding, improving both over time. Laboratory simulations attempt to expose students to realistic situations in a safe environment as they practice clinical decision-making skills, communication, and teamwork (Wilford, 2006). More precisely: \Simulations are defined as activities that mimic the reality of a clinical environment and are designed to demonstrate procedures, decision-making and critical thinking . A simulation may be very detailed and closely simu- late reality, or it can be a group of components that are combined to provide some semblance of reality" (Fawcett, 1992, p. 97). The range of options available to educators is broad, with high fidelity options of- ten the most expensive. From low to high fidelity, options include anatomical models (physical models of the human body), task trainers (equipment that allow students to train a specific skill), role playing, games, computer-assisted instruction, standardized patients (someone who has been trained to portray, in a consistent, standardized man- ner, a patient in a medical situation), virtual reality, low- and high-fidelity mannequins (computerized human models; differentiated by the functionality and the degree to which they are able to approximate real life) (Nehring & Lashley, 2008). High-fidelity simulations are viewed positively by students, who suggest the experi- ences boost confidence, and improve clinical and assessment skills (Nehring & Lashley, 2008). Simulations have been shown to improve student performance (McGaghie, Is- senberg, Petrusa, & Scalese, 2006; Issenberg, McGaghie, Petrusa, Lee Gordon, & Scalese, 4 2009), in areas ranging from Advanced Cardiac Life Support (ALCS) Wayne et al. (2005) to laprascopic suturing (Van Sickle et al., 2008). However, some warn the complexity of high fidelity simulations increases the risk of cognitive overload Haji et al. (2016). In order to further facilitate mindful practice, simulations have been combined with the tenets of deliberate practice Ericsson (2004); Ericsson, Whyte, and Ward (2007). Deliberately practiced simulation activities are to begin with clearly stated objectives, are to include the provision of cues to ensure missteps are not taken or are corrected quickly,